Study reference

Study characteristics

Patient characteristics

Intervention (Index test)

Comparison / Control (Reference test)

Follow-up

Outcome measures and effect size

Comments

Wiglesworth

2009

Bruising as a Marker of Physical Elder Abuse

Type of study^[1]:

Case control study

Setting:

participant’s home; a

neutral site where the participant felt safe; or an inpatient setting

Country:

North-America (University of California)

Conflicts of interest: No conflicts of interest were report

Inclusion criteria:

-65 and older;

-an allegation of physical elder abuse

occurring within the previous 6 weeks; and

-alleged perpetrator

being someone in a position of trust to the older adult

Exclusion criteria: Not mentioned

N= 116

Cases (abuse):

N=48

Age: 77.5 ± 8.1

Sex: 32.2% Male

Controls (not abused):

N=68

Age: 88.5 ± 5.7

Sex: 27.9 % Male

Describe intervention (treatment/procedure/ test):

Examination of skin to document bruising by research nurse. Report falls. 12-item Revised Conflict Tactics Scales (CTS2) Physical assault scale. Elder Abuse Inventory (EAI).
Longitudinal, Experts, All Data (LEAD) methodology

Cut-off point(s): N/A

Comparator test^[2]: N/A

Cut-off point(s): N/A

Describe control

(treatment/procedure/ test):

N/A

Length of follow-up: N/A

For how many participants were no complete outcome data available?

4 (6%)

Outcome measures and effect size (include 95%CI and p-value if available)⁴:

Comparison of bruising location between cases (abused) and controls (non-abused) specified by region:

Head and neck, n(%)

Cases: 10 (20.8%) versus

Controls: 3 (4.4%);

p-value: 0.006

Anterior torso, n(%)

Cases: 4 (8.3%) versus

Controls: 5 (7.3%);

p-value: 0.85

Posterior torso, n(%)

Cases: 7 (14.6%) versus

Controls: 2 (2.9%);

p-value: 0.02

Lateral right arm, n(%)

Cases: 12 (25.0%) versus

Controls: 5 (7.3%);

p-value: 0.008

Right arm, not lateral, n(%)

Cases: 13 (27.1%) versus

Controls: 25 (36.8%);

p-value: 0.27

Left arm, n(%)

Cases: 25 (52.1%) versus

Controls: 25 (36.8%);

p-value: 0.10

Right leg, n(%)

Cases: 7 (14.6%) versus

Controls: 5 (7.3%);

p-value: 0.21

Left leg, n(%)

Cases: 8 (16.7%) versus

Controls: 9 (13.2%);

p-value: 0.61

Authors’ Conclusions: Bruises that occur as a result of physical elder mistreatment are often large (5 cm) and on the face, lateral right arm, or posterior torso. Older adults with bruises should be asked about the cause of the bruises to help ascertain whether physical abuse occurred.

Limitations: Bruises could not always be linked to the actual accident because there was a follow-up max 30 days, bruises could reduce or disappear over follow-up time. Another limitation is that a large proportion did not consented to participate (53%). Further, strict inclusion criteria for the control group were not mentioned.

Chang, 2013

Part II. Risk factors and cutaneous signs of elder mistreatment for the

dermatologist

Type of study:

Overview of the literature on risk factors for elder abuse and cutaneous manifestations

Setting: Dermatology department.

Country: North-America

Conflicts of interest: mentioned

Inclusion criteria: N/A

Describe intervention (treatment/procedure/ test):

N/A

Describe control

(treatment/procedure/ test):

N/A

Length of follow-up: N/A

Outcome measures and effect size (include 95%CI and p-value if available): N/A

Authors’ conclusions: Given the prevalence of elder abuse and neglect and the underreporting of such cases by physicians, a dermatologist should be aware of risk factors and cutaneous manifestations along with their differential diagnoses. There are several potential barriers in detecting and managing elder abuse or neglect, and recognizing these barriers is the first step to reducing them. Having a plan to report or refer suspected elder abuse may be life-saving, and will better serve our growing population of older dermatology patients.

There is a critical need for good quality

evidence on elder mistreatment on which to base clinical practice

limitations: no systematic literature search was performed.

Mosqueda, 2005

The Life Cycle of Bruises in Older Adults

Type of study:

Observational study on the occurrence, progression and resolution of accidental bruises in older adults

Setting: Community-based and skilled nursed facilities

Country: USA

Conflicts of interest: mentioned

Inclusion criteria:

>65y, able to provide informed consent, or assent to surrogate consent, and reside in the community or skilled nursed facility

Exclusion criteria: bruise suspected to be the result of abuse

N= 101

Mean age: 78y

Sex: 66% Female

77% ambulated independently;

55% independent in IADLs.

Describe intervention (treatment/procedure/ test):

Examination for any bruises by an interviewer.

Describe control

(treatment/procedure/ test):

N/A

Length of follow-up:

6 weeks

Loss-to-follow-up:

Intervention:

Not reported.

Incomplete outcome data:

Intervention:

Not reported

Outcome measures and effect size (include 95%CI and p-value if available):

Prevalence: In total, 73% of the patients had at least one bruise. Of 73 the patients with bruises, 49 had one bruise, 17 had two bruises and three had three bruises, three had four bruises and one had five bruises.

Timing: Half of the bruises (54%) resolved by day 6, and most resolved by day 11(80%).

Location: Of the 108 bruises, 89% were on the extremities, and of those, 76% on the dorsal arms.

No bruises were observed on the neck, ears, genitalia, buttocks or soles of the feet.

Area: The size of the bruises varied from 0.12 to 50.0 cm², with widths ranging from 0.3 cm to 10.0 cm.

Colour: most bruises were observed as red (90%) and/or purple (80%), with fewer displaying black (25%), yellow (20%), green (10%) and blue (8%). Yellow increased over time for the first 6 days, with nearly 60% of the bruises showing yellow at day 6.

Authors’ conclusions: Nearly 90% of the bruises were on the extremities. There were no bruises on the neck, ears, genitalia, buttocks, or soles of the feet. Subjects were more likely to know the cause of the bruise if the bruise was on the trunk. One cannot reliably predict the age of a bruise by its colour. People on medications known to affect coagulation pathways and those with compromised function were more likely to have multiple bruises.

Limitations: the study population was not a random sample. Further, It concerns bruises from accidental events (non-abuse); however, it was not 100% sure that all bruises were accidental.

Murphy, 2013

A Literature Review of Findings in Physical Elder Abuse

Type of study:

Literature review

Setting:

Country: Canada, Ontario

Conflicts of interest:

Inclusion criteria:

N/A

Describe intervention (treatment/procedure/ test):

N/A

Describe control

(treatment/procedure/ test):

N/A

Length of follow-up:

N/A

Outcome measures and effect size (include 95%CI and p-value if available):

N/A

Article conclusions: Two-thirds of injuries that occur in elder abuse are to the upper extremity and maxillofacial region. The social context in which the injuries takes place remains crucial to accurate identification of abuse. This includes a culture of violence in the family; a demented,

debilitated, or depressed and socially isolated victim; and a perpetrator profile of mental illness, alcohol or drug abuse, or emotional and/or financial dependence on the victim.

Limitations: due to a lack of literature a variety of studies was included, such as case-control, cross-sectional, case series and case report studies.

Wong, 2017

Imaging Findings in Elder Abuse: A Role for Radiologists

in Detection

Type of study:

Case study (2)

Country: Nort-America, New-York

Conflicts of interest: Not reported

Inclusion criteria:

N= 2

Mean age ± SD:

Case 1: 98 year

Case 2; 90 Year

Sex:

Case 1: Female

Case 2: Female

Describe intervention (treatment/procedure/ test):

To describe radiography in two elderly patients with possible injuries following elder abuse.

Describe control

(treatment/procedure/ test):

N/A

Length of follow-up: N/A

Loss-to-follow-up:

Intervention:

0 (0%)

Outcome measures and effect size (include 95%CI and p-value if available):

N/A

Article conclusion: We hope to raise awareness of elder abuse among diagnostic radiologists to encourage future large-scale research, increased

focus on chronic osseous findings, and the addition of elder abuse to differential diagnoses

Limitations: case series

Rosen, Bloemen en Harpe 2016(b)

Radiologists’ training, experience, and attitudes

Type of study:
Qualitative (semi-structured interviews)

Setting:

Country: North-America, Washington, DC

Conflicts of interest: Not reported.

Inclusion criteria:

N/A

N= 19 interviews with diagnostic radiologists.

Describe intervention (treatment/procedure/ test): Interviews on formal or informal training for elder abuse detection were conducted using a semi-structured format.

Describe control

(treatment/procedure/ test): N/A

Length of follow-up: N/A

Loss-to-follow-up:

Intervention:

0 (0%)

Outcome measures and effect size (include 95%CI and p-value if available):

Of the 19 included radiologists, only two reported any (in)formal training to detect elder abuse. All radiologists believe they have missed cases of elder abuse. There is a desire for elder abuse training. Radiographic finding may be suggestive of elder abuse: high energy injuries, such as rib fractures.

Authors’ conclusions: Radiologists are uniquely positioned to identify elder abuse. Though training in detection is currently lacking, providers expressed a desire for increased knowledge. In addition, radiologists were able to identify radiographic findings suggestive of elder abuse. On the basis of these findings, we plan to conduct additional studies to define pathognomonic injury patterns and to explore how to empower radiologists to incorporate detection

into their practice.

Limitations: Different study population. However, training to recognize injuries seem beneficial.

Rosen, 2016a

Emergency Department Presentations for Injuries in Older Adults Independently Known to be Victims of Elder Abuse

Type of study:

Case reports (from adult protective service records and medical chart reviews) from earlier research (Lachs)

Setting: community dwelling

Country:

North-America

Conflicts of interest: mentioned

Inclusion criteria:

Physical elder abuse victims living in the community of New Haven, CT.

N=572 ED visits were analysed

Describe intervention (treatment/procedure/ test): To describe patterns and circumstances surrounding elder abuse-related and potentially elder abuse-related injuries in older adult ED patients independently known to be victim of elder abuse.

Describe control

(treatment/procedure/ test): N/A

Length of follow-up: 5 years

Loss-to-follow-up:

Intervention:

0 (0%)

Outcome measures and effect size (include 95%CI and p-value if available):

In total 66 ED visits were recognized with high probability of being related to elder abuse, 31 ED visits from 26 patients was for an injury caused by physical elder abuse. For these visits, 81% were female, and the abuser was mostly the victim’s husband (25%) or daughter (19%). Fifteen percent of victims were cognitively impaired, and 15% of victims and 27% of abusers had a known psychiatric diagnosis.

Authors’ conclusions: Our work expands the existing knowledge about injury patterns and circumstances consistent with and suspicious for physical elder abuse and highlights the important role of the ED in screening and identification. Future research is needed to comprehensively and systematically examine and describe common injury patterns, physical findings, and forensic biomarkers in elder abuse victims presenting to the ED and compare these to other geriatric injury victims. Ultimately, clinical decision rules should be designed and validated to assist busy emergency providers in identifying potential elder abuse victims.

Limitations: can be used for locations of physical abuse injuries “We found that injuries, and bruising in particular, are most commonly found on the upper extremities. Victims of physical abuse were also likely to have injuries on their face and neck. This confirms previous findings from multiple studies”

Greenbaum, 2006

Burn Injuries Inflicted on Children or the

Elderly: A Framework for Clinical and

Forensic Assessment

Type of study:

A Framework for Clinical and Forensic Assessment

Setting:

Country: North-America

Conflicts of interest: None

Inclusion criteria:

N/A

Describe intervention (treatment/procedure/ test): N/A

Describe control

(treatment/procedure/test): N/A

Length of follow-up: N/A

Outcome measures and effect size (include 95%CI and p-value if available): N/A

Authors’ conclusions: none

Limitations: Provides a framework concerning laws and policies in Nort-America regarding elder abuse. In particular, and how to report in specific situations.

Danesh, 2015

The role of the dermatologist in detecting

elder abuse and neglect

Type of study: literature overview

Country: USA

Conflicts of interest: None

Inclusion criteria:

Describe intervention (treatment/procedure/ test): N/A

Describe control

(treatment/procedure/ test): N/A

Length of follow-up: N/A

Outcome measures and effect size (include 95%CI and p-value if available): N/A

Authors’ conclusions: Dermatologists are uniquely positioned to identify and manage suspected cases of elder abuse given their expertise in distinguishing skin lesions of abuse from organic medical disease and their patient populations with strong elderly representation. Like physicians across medical specialties, dermatologists must be familiar with those aspects of elder abuse screening, diagnosis, management, and reporting that are unique to their field and to those aspects that are applicable to all health care providers. There remains a great need for studies in dermatology to assess the value of screening, the sensitivity and specificity of signs and symptoms of abuse, and the attitudes of residents and practicing physicians to the management and reporting of abuse.

Limitations: Concerns a different population (role of a dermatologist). No systematic literature search was performed.

Ziminiski, 2013

Injury Patterns and Causal Mechanisms of

Bruising in Physical Elder Abuse

Type of study:

Secondary data analysis Based on Wiglesworth 2009

Setting:

participant’s home; a

neutral site where the participant felt safe; or an inpatient setting

Country:

North-America (University of California)

Conflicts of interest: None

Inclusion criteria:

-65 and older;

-an allegation of physical elder abuse

occurring within the previous 6 weeks; and

-alleged perpetrator

being someone in a position of trust to the older adults

Exclusion criteria: Not mentioned

N=67

Age: 76 ± 8 years

Sex: 72% Female

Describe intervention (treatment/procedure/ test):

To describe the mechanisms of injury associated with characteristics of the bruises in a sample of elders who experienced physical elder abuse

Describe control

(treatment/procedure/ test):

N/A

Length of follow-up: 12 months

For how many participants were no complete outcome data available?

Not reported

Outcome measures and effect size (include 95%CI and p-value if available):

The most common bruising locations were the lateral/anterior arms (n = 23, 34.3%), head and neck (n = 10, 14.9%), and posterior torso (n = 7, 10.4%). Ten (14.9%) elders sustained head and neck bruises.

Article conclusions: Forensic nurses treat the immediate effects of violence

and are uniquely positioned to intervene with local investigation agencies to ensure patient safety. This study suggests bruising to the lateral/anterior arms and to the head/neck is characteristic of physical elder abuse. Therefore, forensic nurses should pay particular attention to bruising in these areas when conducting abuse assessments. In addition, the findings suggest bruising to the arms is a result of conflict and not of ‘‘rough’’ caregiving (id est, transferring someone by the arms); therefore, forensic nurses need to be open minded to the possibility of elder abuse occurring in caregiving situations. This reinforces the recommendation that every older adult with a bruise be questioned about the possibility of elder abuse

Limitations: The sample size is small and limits the findings to what can be learned from this specific set of abuse incidents.

Palmer, 2013

Elder abuse: Dermatologic clues and critical solutions

Type of study:

Literature overview

Country: North-America

Conflicts of interest: None

Inclusion criteria: N/A

Describe intervention (treatment/procedure/ test):

Analyses of risk factors, clinical signs, reporting requirements, and prevention of elder abuse.

Describe control

(treatment/procedure/ test):

N/A

Length of follow-up: N/A

Outcome measures and effect size (include 95%CI and p-value if available):

Authors’ conclusions: The identification and treatment of elder abuse by the dermatologist requires a high index of suspicion, awareness of the clinical signs of elder abuse, and knowledge of reporting requirements that are defined by each state. Thoughtful screening for elder abuse and prompt reporting should be an important part of every dermatologist’s practice. Further research

is required to learn how to best substantiate

the presence of abuse and to differentiate abuse from common conditions.

Limitations: no systematic literature search was performed. Interestingly, 7 types of elder abuse were reported; physical abuse, sexual abuse, emotional abuse, neglect, self-neglect, abandonment and financial/material exploitation.